Anthem Blue Cross Blue Shield, which has most of Kentucky's private insurance market, has a new policy that allows it to decide whether to pay a claim for emergency treatment -- after it sees the final diagnosis, Miranda Combs reports for Lexington's WKYT-TV.
"That says they're going to look at the final diagnosis when you come to the emergency department and use that to determine if they refuse it saying it was a non-emergent event," Dr. Ryan Stanton, an emergency physician for 12 years, told Combs. "The biggest concern I have is that people are going to use this as a reason not to go to the emergency room for true emergencies or when they think they have an emergency."
Alison Wrenne has first hand experience of this new policy. Wrenne told Combs she was at home when the pain in her abdomen became so severe, she fell to the floor. After waiting for a while to see if it would subside, she went to the emergency room on the advice of a friend who is a physician assistant. At the ER, Wrenne had an ultrasound to confirm it was an ovarian cyst that had ruptured, which was not life-threatening, but her doctor told her there was no way for her to know that, she said.
"A couple of months later, I got a bill from the hospital and a letter from Anthem saying they had rejected my claim and that I should have . . . visited my local practitioner," Wrenne said. The bill was for more than $4,000.
Stanton, a regular medical contributor to WKYT, told Combs, "This policy flies in the face of the 'prudent layperson standard'," part of the "Patient's Bill of Rights" in the 2010 Patient Protection and Affordable Care Act. The standard "says that if you feel like you have an emergency, then you have the right to go to the emergency room and you have the right for that to be covered by your insurance company."
Stanton said Kentucky is one of just a few states where Anthem is enforcing the new policy. Anthem says the policy has been in place since 2015, but Stanton said he just started seeing Anthem refuse payments in his ER last summer.
Anthem told WKYT, “Anthem’s goal is to ensure the broadest access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage our members to receive care in the most appropriate setting.”
It added, “Emergency rooms treat life- and limb- threatening situations, and if a member feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary-care physicians should always be the first medical professional members see with non-emergency medical concerns, with urgent care, telemedicine, retail clinics and Anthem’s free 24-7 nurse lines available to assist members in after-hours situations.”
Combs reports, "Anthem goes on to say they will continue coverage to anyone that is directed to the emergency room by another medical provider and if a patient thinks they are in an emergency situation Anthem says they still highly suggest going to the hospital or calling 911. Anthem says they will cover services if they were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday. They say all visits will be reviewed by the hospitals layperson before the insurance company makes a decision on the coverage of the visit."
Medical professionals push back
Patrick Padgett, executive vice president of the Kentucky Medical Association, writes in an op-ed for the Lexington Herald-Leader that Anthem controls nearly 60 percent of Kentucky's commercial health-insurance market, "so the policies they adopt have an enormous impact on the delivery of health care in our state."
He said a failed merger between Anthem and Cigna has left Anthem facing a lawsuit with a possible $1 billion payment to Cigna, "and these new policies send the clear message that in the desperate scramble for profit, your comfort and convenience as a patient are secondary."
He offered examples of policies on emergency-room payments, a requirement that clients only use a MRI provider of the company's choosing, and denial of authorization for procedures done the same day as an examination.
"Comfort and convenience should be essential parts of the health care system," Padgett writes. "They should not be sacrificed at the altar of disastrous business decisions."
The American Medical Association asked Anthem to immediately rescind the emergency-room policy in states where it has been put into effect and halt implementation in all other states.
“Patients and caregivers should never second-guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion,” AMA Executive Vice President and CEO Dr. James L. Madara told Anthem President and CEO Joseph Swedish in a letter on June 29. “Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.”
The American College of Emergency Physicians, which was instrumental in getting Congress to pass the "prudent layperson" standard, said in October that Anthem has developed a "secret list of diagnoses that they will not pay for, such as "chest pain on breathing" and blood in the urine, even if the patient thought it was a medical emergency." The organization commissioned a poll from Morning Consult that found among other things, 67 percent of Americans oppose this policy to deny coverage for emergency care.
"That says they're going to look at the final diagnosis when you come to the emergency department and use that to determine if they refuse it saying it was a non-emergent event," Dr. Ryan Stanton, an emergency physician for 12 years, told Combs. "The biggest concern I have is that people are going to use this as a reason not to go to the emergency room for true emergencies or when they think they have an emergency."
"A couple of months later, I got a bill from the hospital and a letter from Anthem saying they had rejected my claim and that I should have . . . visited my local practitioner," Wrenne said. The bill was for more than $4,000.
Stanton, a regular medical contributor to WKYT, told Combs, "This policy flies in the face of the 'prudent layperson standard'," part of the "Patient's Bill of Rights" in the 2010 Patient Protection and Affordable Care Act. The standard "says that if you feel like you have an emergency, then you have the right to go to the emergency room and you have the right for that to be covered by your insurance company."
Stanton said Kentucky is one of just a few states where Anthem is enforcing the new policy. Anthem says the policy has been in place since 2015, but Stanton said he just started seeing Anthem refuse payments in his ER last summer.
It added, “Emergency rooms treat life- and limb- threatening situations, and if a member feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary-care physicians should always be the first medical professional members see with non-emergency medical concerns, with urgent care, telemedicine, retail clinics and Anthem’s free 24-7 nurse lines available to assist members in after-hours situations.”
Combs reports, "Anthem goes on to say they will continue coverage to anyone that is directed to the emergency room by another medical provider and if a patient thinks they are in an emergency situation Anthem says they still highly suggest going to the hospital or calling 911. Anthem says they will cover services if they were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday. They say all visits will be reviewed by the hospitals layperson before the insurance company makes a decision on the coverage of the visit."
Medical professionals push back
Patrick Padgett, executive vice president of the Kentucky Medical Association, writes in an op-ed for the Lexington Herald-Leader that Anthem controls nearly 60 percent of Kentucky's commercial health-insurance market, "so the policies they adopt have an enormous impact on the delivery of health care in our state."
He said a failed merger between Anthem and Cigna has left Anthem facing a lawsuit with a possible $1 billion payment to Cigna, "and these new policies send the clear message that in the desperate scramble for profit, your comfort and convenience as a patient are secondary."
He offered examples of policies on emergency-room payments, a requirement that clients only use a MRI provider of the company's choosing, and denial of authorization for procedures done the same day as an examination.
"Comfort and convenience should be essential parts of the health care system," Padgett writes. "They should not be sacrificed at the altar of disastrous business decisions."
The American Medical Association asked Anthem to immediately rescind the emergency-room policy in states where it has been put into effect and halt implementation in all other states.
“Patients and caregivers should never second-guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion,” AMA Executive Vice President and CEO Dr. James L. Madara told Anthem President and CEO Joseph Swedish in a letter on June 29. “Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.”
The American College of Emergency Physicians, which was instrumental in getting Congress to pass the "prudent layperson" standard, said in October that Anthem has developed a "secret list of diagnoses that they will not pay for, such as "chest pain on breathing" and blood in the urine, even if the patient thought it was a medical emergency." The organization commissioned a poll from Morning Consult that found among other things, 67 percent of Americans oppose this policy to deny coverage for emergency care.
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